This entry is our analysis of a considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text The Summary conveys the findings and views expressed in the . Below is a commentary from Drug and Alcohol Findings.

Magill M., Ray L.A.Journal of Studies on Alcohol and Drugs: 2009, 70, 516–527.Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Magill at molly_magill@brown.edu. You could also try this alternative source.

Cognitive-behavioural therapies are among the most widespread and influential approaches to substance use, yet this analysis found they conferred just a small advantage over other therapies. Perhaps other features are more important than the therapeutic 'brand'.

Most of the studies compared cognitive-behavioural therapies against treatment as usual, many against other specific therapies, and a few against no treatment. Another few tested cognitive-behavioural therapies as an add-on treatment. Across all these studies, cognitive-behavioural therapies improved substance use outcomes by a small but statistically significant degree. The size of this effect meant that with cognitive-behavioural therapy, another 8% of people would do better than the
typical
Specifically, 58% of cognitive-behavioural patients performed better than the median for the comparison group.
person in the comparison group whose treatment did not include cognitive-behavioural therapy. However, there was significant variation in impact across the studies.

As expected, the therapy's effectiveness was thrown in to sharpest relief when compared to no treatment. The large effect size across these studies meant that another 29% of people had better substance use outcomes than the typical non-treated individual in the comparison group. Once again however, there was significant variation in impact across the studies. In contrast, there was a consistent but much smaller improvement in outcomes when the comparison group received either treatment as usual, or another specific therapy.

Contradicting conclusions reached by other analysts, there was no evidence that the benefits of cognitive-behavioural therapies persisted and/or grew over time more than those from other approaches. Impacts registered in studies with post-treatment follow-ups were slightly lower than the overall impact, and the relative benefits of cognitive-behavioural therapies diminished between 6–9 months after treatment and 12 months.

Across the six studies where the main problem drug was cannabis, cognitive-behavioural therapies had a consistent moderate impact which was larger than the all-drugs average. This meant that instead of (as across all the studies) another 8% of people doing better than typical for the comparison group, in the cannabis studies the figure was 19%. Impacts remained significant and consistent but small for alcohol studies, variable and small when the problem drugs were either stimulants or opiates, but became insignificant when the participants used multiple drugs.

The analysts concluded that cognitive-behavioural therapies had demonstrated their utility across a large and diverse sample of studies and for different types of substance use dependencies, and had done so under rigorous conditions for establishing efficacy, including comparisons with other active treatments. Effects were strongest among cannabis users and might also have been larger with women, when the therapies were relatively brief, and combined with another psychosocial therapy rather than medication. Group-based delivery was no less effective than individual.

commentaryCognitive-behavioural approaches are perhaps the world's most commonly used and widely researched formal psychological therapies, applied often with good results to a range of psychological problems. For substance use too, these therapies have an impressive research record (for example for problem drinking), but this is partly because more good quality studies have been done than in respect of competing approaches.

In the featured analysis, only with respect to cannabis use studies did cognitive-behavioural approaches record a major advantage. But of these six studies, three included no-treatment control groups, and when there was a comparison treatment, often it was much briefer then the cognitive-behavioural therapy, or in one case, deliberately non-interventionist. Greater impact across these studies might simply have reflected the relative weakness of the comparators.

Findings of little difference between outcomes from different therapies fit with the discovery that, despite in theory working through very different psychological processes, in practice cognitive-behavioural and other therapies create change through similar mechanisms. Studies have rarely confirmed that the theoretical mechanisms behind cognitive-behavioural therapies actually were responsible for substance use outcomes. Such findings direct attention away from the 'brand' of the therapy to 'common factors' which cut across different therapies, such as entering a setting within which the patient expects to be helped to get better, the credibility of the therapy to both patient and therapist, its ability to (for that patient) make ordered sense of the patient's 'disorder', in doing so to structure a route out of that disorder which generates optimism, its ability to provide a platform for engaging the client in their recovery, and the therapist's ability to create a supportive environment which facilitates these processes. Perhaps the greatest common factor lies in the patients and clients. Typically they have reached the point where they desperately want to get better, have realised they need help to do so, and have decided to follow a culturally sanctioned route to gaining that help – formal treatment.

Where cognitive-behavioural approaches sometimes have scored better than alternatives is in the persistence of their effects. Gains relative to other therapies have been found to emerge only after the end of therapy and to grow over the follow-up period. This has been observed for some psychological and psychiatric problems (12), for cocaine use problems (12), and recently in respect of cannabis dependence. The featured analysis seems to contradict this impression, but its finding of diminishing returns in the year after treatment reflects results from different sets of studies at the different time periods. Other ways the studies differed might account for this apparent waning. More convincing are results from different time points within the same study.

Recent national guidance from Britain's National Institute for Health and Clinical Excellence (NICE) recommended against cognitive-behavioural therapy as a routine treatment for drug problems, suggesting its main role was in tackling accompanying depression and anxiety. However, the analyses on which this was based did not show that cognitive-behavioural therapy was ineffective, just that it was not convincingly more effective than other well structured therapies. If this is the case, then the decision between such therapies can safely be taken on the grounds of what makes most sense to patient and therapist, the therapist's training, availability, and cost. In respect of cost and availability, cognitive-behavioural therapy may (more evidence is needed) prove to have two important advantages. The first is that effects may persist and even amplify without having to continue in therapy. The second is that it lends itself to manualisation to the point where it can be packaged as an interactive computer program and made available in services lacking trained therapists – potentially a crucial advantage for widespread implementation. In the UK implementation has been held back by the shortage of therapists, an obstacle currently being addressed by a government-funded training initiative.

Thanks for their comments on this entry in draft to Molly Magill of the Center for Alcohol and Addiction Studies at Brown University in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.